DVBCWMW1 ;ALB/CMM MUSCLES WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. If there are periods of flare-up of residuals of muscle injury:
;; a. State their severity, frequency, and duration.
;;
;;
;; b. Name the precipitating and alleviating factors.
;;
;;
;; c. Estimate to what extent, if any, they result in additional
;; limitation of motion or functional impairment during the
;; flare-up.
;;
;;
;; 2. If injury is due to a missile: initial treatment in the field,
;; length of initial hospitalization and any surgeries or other
;; repairs undertaken, time until return to duty or limited duty
;; or determination that duty could not be resumed.
;;
;;
;; 3. Record exact muscles injured or destroyed and describe.
;;
;;
;; 4. Record any associated injuries, particularly those affecting
;; bony structures, nerves or vascular structures and specify the
;; nature of treatment required.
;;
;;
;; 5. Describe present symptoms of muscle pain, activity limited by
;; fatigue or inability to move joint through a portion of its
;; range; and the degree to which this interferes with activities
;; of daily living.
;;
;;
;; 6. For tumors of muscle, describe onset of symptoms, date(s) of
;; biopsy and/or surgical excision and residual defects. If
;; malignant neoplasm, need dates of diagnosis, dates and type of
;; treatment, and date of late treatment.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. Entry and exit wound scars as well as dimensions.
;;
;;
;; 2. Tissue loss comparison, and specify muscle group(s) penetrated.
;;
;;
;; 3. Scar formation measurement (sensitivity, tenderness, etc.)
;;
;;
;; 4. Adhesions.
;;
;;
;; 5. Tendon damage.
;;
;;
;; 6. Bone, joint or nerve damage.
;;
;;
;; 7. Muscle strength.
;;
;;
;; 8. Muscle herniation and, if any, whether supported by truss or
;; belt.
;;
;;
;; 9. Loss of muscle function. Can muscle group move joint through
;; normal range with sufficient comfort, endurance and strength
;; to accomplish activities of daily living? Can muscle group
;; move joint independently through useful ranges of motion but
;; with limitation by pain or easy fatigability or weakness?
;; Can muscle group move joint only with assistance or with
;; gravity eliminated? Is there no ability of muscle group to
;; move joint even with gravity eliminated and joint passively
;; moveable? Is any muscle contraction felt?
;;
;;
;; 10. If joint function is affected:
;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
;; of motion, including movement against gravity and against
;; strong resistance.
;;
;;TOF
;; b. State to what extent (if any) and in which degrees (if
;; possible) the range of motion or function is ADDITIONALLY
;; LIMITED by pain, fatigue, weakness, or lack of endurance
;; following repetitive use or during flare-ups. If more
;; than one of these is present, state, if possible, which
;; has the major functional impact.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. If applicable, x-rays of joint(s) involved in two planes or
;; anatomic area involved if not recorded in past (once taken,
;; the x-rays do not need to be repeated).
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWMW1 4173 printed Nov 22, 2024@17:02:56 Page 2
DVBCWMW1 ;ALB/CMM MUSCLES WKS TEXT - 1 ; 6 MARCH 1997
+1 ;;2.7;AMIE;**12**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;
+4 ;;
+5 ;;B. Medical History (Subjective Complaints):
+6 ;;
+7 ;; Comment on:
+8 ;; 1. If there are periods of flare-up of residuals of muscle injury:
+9 ;; a. State their severity, frequency, and duration.
+10 ;;
+11 ;;
+12 ;; b. Name the precipitating and alleviating factors.
+13 ;;
+14 ;;
+15 ;; c. Estimate to what extent, if any, they result in additional
+16 ;; limitation of motion or functional impairment during the
+17 ;; flare-up.
+18 ;;
+19 ;;
+20 ;; 2. If injury is due to a missile: initial treatment in the field,
+21 ;; length of initial hospitalization and any surgeries or other
+22 ;; repairs undertaken, time until return to duty or limited duty
+23 ;; or determination that duty could not be resumed.
+24 ;;
+25 ;;
+26 ;; 3. Record exact muscles injured or destroyed and describe.
+27 ;;
+28 ;;
+29 ;; 4. Record any associated injuries, particularly those affecting
+30 ;; bony structures, nerves or vascular structures and specify the
+31 ;; nature of treatment required.
+32 ;;
+33 ;;
+34 ;; 5. Describe present symptoms of muscle pain, activity limited by
+35 ;; fatigue or inability to move joint through a portion of its
+36 ;; range; and the degree to which this interferes with activities
+37 ;; of daily living.
+38 ;;
+39 ;;
+40 ;; 6. For tumors of muscle, describe onset of symptoms, date(s) of
+41 ;; biopsy and/or surgical excision and residual defects. If
+42 ;; malignant neoplasm, need dates of diagnosis, dates and type of
+43 ;; treatment, and date of late treatment.
+44 ;;
+45 ;;
+46 ;;C. Physical Examination (Objective Findings):
+47 ;;
+48 ;; Address each of the following and fully describe current findings:
+49 ;; 1. Entry and exit wound scars as well as dimensions.
+50 ;;
+51 ;;
+52 ;; 2. Tissue loss comparison, and specify muscle group(s) penetrated.
+53 ;;
+54 ;;
+55 ;; 3. Scar formation measurement (sensitivity, tenderness, etc.)
+56 ;;
+57 ;;
+58 ;; 4. Adhesions.
+59 ;;
+60 ;;
+61 ;; 5. Tendon damage.
+62 ;;
+63 ;;
+64 ;; 6. Bone, joint or nerve damage.
+65 ;;
+66 ;;
+67 ;; 7. Muscle strength.
+68 ;;
+69 ;;
+70 ;; 8. Muscle herniation and, if any, whether supported by truss or
+71 ;; belt.
+72 ;;
+73 ;;
+74 ;; 9. Loss of muscle function. Can muscle group move joint through
+75 ;; normal range with sufficient comfort, endurance and strength
+76 ;; to accomplish activities of daily living? Can muscle group
+77 ;; move joint independently through useful ranges of motion but
+78 ;; with limitation by pain or easy fatigability or weakness?
+79 ;; Can muscle group move joint only with assistance or with
+80 ;; gravity eliminated? Is there no ability of muscle group to
+81 ;; move joint even with gravity eliminated and joint passively
+82 ;; moveable? Is any muscle contraction felt?
+83 ;;
+84 ;;
+85 ;; 10. If joint function is affected:
+86 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
+87 ;; of motion, including movement against gravity and against
+88 ;; strong resistance.
+89 ;;
+90 ;;TOF
+91 ;; b. State to what extent (if any) and in which degrees (if
+92 ;; possible) the range of motion or function is ADDITIONALLY
+93 ;; LIMITED by pain, fatigue, weakness, or lack of endurance
+94 ;; following repetitive use or during flare-ups. If more
+95 ;; than one of these is present, state, if possible, which
+96 ;; has the major functional impact.
+97 ;;
+98 ;;
+99 ;;D. Diagnostic and Clinical Tests:
+100 ;;
+101 ;; 1. If applicable, x-rays of joint(s) involved in two planes or
+102 ;; anatomic area involved if not recorded in past (once taken,
+103 ;; the x-rays do not need to be repeated).
+104 ;; 2. Include results of all diagnostic and clinical tests conducted
+105 ;; in the examination report.
+106 ;;
+107 ;;
+108 ;;E. Diagnosis:
+109 ;;
+110 ;;
+111 ;;Signature: Date:
+112 ;;END
